Mobility among adolescents and young people (AYP) is a key factor influencing their access to sexual and reproductive health rights (SRHR) services. Young migrants are more likely to experience gender-based violence and their access to SRHR services and education is often limited in their new communities. We conducted a scoping review which aimed to map what is known about the extent and type of interventions focused on SRHR for mobile adolescents and young people (mAYP) in sub-Saharan Africa. We followed Arksey and O’Mally’s (2005) steps for conducting scoping reviews: 1. Identifying the research question; 2. Identifying relevant studies; 3. Study selection; 4. Charting the data and 5. Collating, summarising and reporting the results. We searched four databases identifying 1,069 articles. After screening, 25 articles were included. Many studies were conducted in Uganda (n = 12), reported on conflict-related mobility (n = 15), and focused on HIV (n = 11). Two main intervention types were identified: Links to service provision and Knowledge, information, and skills development. Implementation facilitators included recruiting community health promoters, mentors and peer supporters. Implementation barriers included limited literacy, social norms, access to facilities and stigma associated with accessing services. Research exploring SRHR interventions for mAYP is limited in sub-Saharan Africa. Future research and interventions should be underpinned by an understanding of young people’s health and wellbeing more broadly, and foreground the social, cultural, religious and economic factors shaping mAYP’s SRH needs.

In Sub-Saharan Africa, unmet need for contraceptives often remains high among adolescent girls and young women (AGYW), leading to unintended pregnancies. Yathu Yathu, a cluster-randomised trial of a community-based intervention conducted in two communities in Lusaka, Zambia (2019–2021), aimed to provide sexual and reproductive health services, including contraceptive services, to adolescents and young people. The trial showed no impact on pregnancy related outcomes. Hence, this analysis examined the characteristics of AGYW aged 15–24 with an unmet need for modern contraceptives and who experienced an unintended pregnancy. We also explored access to and reach of contraceptive services through Yathu Yathu. Secondary analysis of Yathu Yathu endline survey data. Using logistic regression, adjusted for cluster, we explored factors associated with unmet need for modern contraceptives and unintended pregnancies among AGYW in the intervention arm and assessed whether these associations differed in the control arm. Using routinely collected service delivery data from the intervention arm, numbers of AGYW accessing hormonal contraceptive services were described by age, community, educational attainment, and marital status. In the intervention arm, 395 AGYW ever had sex. Unmet need for modern contraceptives was 40.6 https://clinicaltrials.gov/ct2/show/NCT04060420 ; and ISRCTN75609016. Registration date: 2019-08-12.

Menstrual cups could be a sustainable menstrual material for adolescent girls and young women (AGYW) in sub-Saharan Africa. Yathu Yathu was a cluster-randomized trial of community-based delivery of HIV and sexual and reproductive health services to young people in Lusaka, Zambia. Among services available through the intervention were menstrual products, including menstrual cups. We explored knowledge of menstruation and menstrual products, acceptability, and experiences of using cups among AGYW aged 15–24. We share lessons learned on how to distribute cups through community-based strategies to AGYW in urban communities. Through community-based, peer-led spaces (hubs), AGYW could access menstrual products, including pads and menstrual cups. We conducted four focus group discussions, two with AGYW aged 15–19 (n = 9) and 20–21 (n = 8) who had accessed different menstrual products through Yathu Yathu and two with AGYW aged 15–19 (n = 5) and 20–24 (n = 9) who had accessed menstrual cups. Four interviews were conducted with four AGYW (15–19, n = 2; 20–24, n = 2) who had accessed cups, and four with two AGYW who were enrolled in a qualitative cohort. Data were analyzed thematically. ‘Surprise’ and ‘fear’ were initial reactions from most AGYW who saw the cups for the first time at Yathu Yathu hubs. Misconceptions that cups cause cancer and fears that they could get stuck in the vagina, cause sore, vagina enlargement, and loss of virginity were raised by AGYW. The desire to try the cup, use an alternative menstrual product and information gained at the hubs facilitated access. Use of the cup was comfortable, and cups were said to be cost-effective and durable. Advantages over pads included: the absence of odor, easy to maintain, and environmentally friendly: “it is hygienic, and it is even easy to maintain”. Challenges included pain, discomfort, and failure to or incorrectly inserting the cup at initial use. When faced with challenges using the cup, AGYW reported going back to the hub for additional information and demonstrations on use. Despite concerns, misconceptions and initial challenges, cups were acceptable among AGYW. Free distribution of cups provides an opportunity to address menstrual health challenges among AGYW. However, as a new product, there is need to increase awareness and provide detailed information on use.

Like in many countries, coverage of sexual and reproductive health (SRH) services among adolescents and young people (AYP) aged 15–24 remains low in Zambia. Increasing coverage of SRH services requires interventions that are responsive to the needs and preferences of AYP. We conducted a discrete choice experiment (DCE) to elicit AYP’s preferences for SRH service delivery in Lusaka, Zambia. A cross-sectional DCE was conducted with AYP aged 15–24 years. Consenting participants were presented with alternative SRH service delivery strategies represented by six attributes, namely: location, type of provider, type of services, service differentiation by sex, availability of edutainment, and opening hours. Multinomial logit and random parameters logit models were used to analyse the data. All variables were effect coded. A total of 423 AYP aged 15–24 years (61

Across sub-Saharan Africa, stigma levels have been decreasing but not enough to achieve the 95-95-95 HIV targets by 2030. Current global HIV frameworks have identified stigma reduction, context specific interventions, and community mobilization as critical to enabling more effective uptake of HIV services. We conducted a retrospective analysis of longitudinal qualitative and quantitative data collected in 21 urban communities in Zambia and South Africa involved in the HPTN071 (PopART) trial between 2014 and 2019. We illustrate in four communities how three sociostructural features of communities intersected with stigma at the community level: intergroup tensions, the community responses to sociodemographic change, and the local history of HIV initiatives. Tension between different social groups often functioned as a catalyst for stigmatizing attitudes. Sociodemographic change at community level took the form of rapid housing development, population expansion, and outsiders moving in. The ability and willingness of a community to respond to this sociodemographic change and antistigma initiatives influenced HIV stigma. Our findings illustrate patterns in how community-level dynamics influence the trajectory of stigma and point toward a key strategy for accelerating reductions in stigma across sub-Saharan Africa. Community-led approaches, which take local context and dynamics into account, are critical to address the societal enablers of HIV, including eliminating stigma and discrimination. Further, stigma-reduction activities should build on community HIV history, be sensitive to involuntary disclosure, speak to "othering" linked to intergroup tensions, and be a consistent component of HIV programming, given the protection such programming provides against stigma and discrimination.

There is little evidence regarding community-based delivery of STI testing and treatment for youth aged 15–24 (AYP) in Zambia. In a cluster-randomised trial, we evaluated whether offering syndromic STI screening through community-based, peer-led sexual and reproductive health services (Yathu Yathu) with referral to a local health facility for testing, increased self-reported testing for STIs (other than HIV) among AYP. Two communities in Lusaka were divided into 10 zones each (20 zones in total); by community, zones were randomly allocated (1:1) to Yathu Yathu or control. Monitoring data were used to describe syndromic STI screening through Yathu Yathu and an endline cross-sectional survey used to evaluate the impact of Yathu Yathu on self-reported ever and recent (last 12 months) STI testing. 10,974 AYP accessed Yathu Yathu; 66.6% (females—67.7%; males—64.7%) were screened for STIs, 6.2% reported any STI symptoms. In the endline survey, 23.3% (n = 350/1501) of AYP who ever had sex ever STI tested; 13.5% (n = 174/1498) who had sex in the last 12 months recently STI tested. By trial arm, there was no difference in self-reported ever or recent STI testing among all AYP. Among men aged 20–24, there was evidence that ever STI testing was higher in the Yathu Yathu compared to control arm (24.1% vs 16.1%; adjPR = 1.67 95%CI = 1.02, 2.74; p = 0.04). Among AYP who ever STI tested, 6.6% (n = 23) reported ever being diagnosed with an STI. Syndromic STI management through community-based, peer-led services showed no impact on self-reported STI testing among AYP. Research on community-based delivery of (near) point-of-care diagnostics is needed. Trial registration number(s) : NCT04060420 https://clinicaltrials.gov/ct2/show/NCT04060420 ; and ISRCTN75609016; https://doi.org/10.1186/ISRCTN75609016 .

Abstract Background The Yathu Yathu (“For Us, By Us”) cluster-randomized trial (CRT) evaluated a peer-led community-based sexual and reproductive health(SRH) intervention implemented to address persistent barriers to SRH service use among adolescents and young people (AYP). We report the impact of the intervention on coverage of key SRH services among AYP. Methods The trial was conducted from Jul 2019-Oct 2021 in two urban communities in Lusaka, Zambia, divided into 20 zones (~ 2350 AYP/zone). Zones were randomly allocated to intervention (N = 10) or control (N = 10) arm. In all zones, a census was conducted and all AYP aged 15-24-years offered participation. The intervention consisted of peer-led community-based hubs providing SRH services; a prevention points card (PPC) system to incentivize and track SRH service use and community engagement. This paper reports on the outcome of coverage (accessing at least one key SRH service), comparing intervention and control arms using PPC data and standard methods of analysis for CRTs. Results Among enumerated AYP, 93.6% (14,872/15,894) consented to participate from intervention zones and 95.1% (14,500/15,255) from control zones. Among those who accepted a PPC, 63.8% (9,493/14,872) accessed at least one key SRH service during the study period in the intervention arm, compared to 5.4% (776/14,500) in the control arm (adjPR 12.3 95%CI 9.3–16.2, p < 0.001). Conclusions The Yathu Yathu intervention increased coverage of key SRH services among AYP and reached two-thirds of AYP. These findings demonstrate the potential of providing peer-led community-based SRH services. Trial registration ISRCTN75609016 (11/10/2021), clinicaltrials.gov number NCT04060420 (19/08/2019); retrospectively registered.

Background In Zambia, from March 2019, strict adherence to public health guidelines during implementation of essential or COVID-19 related research studies inadvertently impacted the conduct of community engagement (CE). We share our experience of establishing and navigating CE in a TB research study pivoted to include COVID-19 in Zambia. Methods Different approaches were adapted to solicit CE for different study phases. Phone-based individual conversations (n=6) with community representatives and district health officials, and phone-based group discussions (n=4) with community members were held to obtain initial COVID-19 community experiences and informed protocol development. In addition, low-risk face-to-face meetings (n=8) were held with community members, following COVID-19 guidelines, to deepen understanding of the community experiences. Prior to study commencement, meetings (n=4) with community representatives were held, leading to formation of a COVID-19 Community Team (CCT) to guide study implementation. Meetings with the CCT (n=5), health facility staff (n=3), and sensitization activities (n=20) were held during implementation, and these CE activities were evaluated using observations (n=8), individual interviews (n=8) and focus group discussion (FGD: n=5). Results Community engagement helped researchers to identify information and knowledge gaps and dynamics, local experience, and supported interaction between community and the health facility. Further, establishing the CCT generated community agency for COVID-19. However, phone-based conversations and discussions, though useful, were limited in quality by poor network, limited number of participants on a single call, and limited ownership of a working phone. Face-to-face CE activities were also undermined by strict adherence to COVID-19 public health and institutional guidelines that prevented social etiquette (e.g. handshakes) and more extended community interactions. Conclusion Although establishing and navigating CE during the COVID-19 pandemic was feasible, the reach and quality of community engagement was compromised by COVID-19 restrictions. Therefore, a combination of the remote and face-to-face research approaches is required going forward.

Introduction Adolescents and young people (AYP) aged 15–24 years have the least access to facility-based sexual and reproductive health (SRH) services, including HIV services. The Yathu-Yathu cluster-randomized trial (CRT) in Zambia tested whether a novel peer-led community-based approach increased knowledge of HIV status amongst AYP. In this nested case-control study, we aimed to identify factors associated with non-attendance to the Yathu Yathu hubs by adolescent boys and young men (ABYM) aged 18-24-years. Methods Yathu Yathu was a CRT conducted in two communities in Lusaka, Zambia, with 10 intervention and 10 control zones. AYP in all zones were offered prevention points cards (PPC), which incentivized and tracked service use at the hubs and health facility. In intervention zones, services were provided to AYP through community-based spaces (hubs) led by peer support workers. In these zones, cases were defined as those not having accessed any service at a hub and controls as those that accessed at least one service. Data were collected from October 2020 to January 2021 and analysed using methods appropriate for unmatched case-control studies. Results 161 cases and 160 controls consented to participate in the study. Participants aged 20–24 years (adjOR 1.99, 95%CI 1.26–3.12, p = 0.003), who were educated up to college level (adjOR 8.47,95%CI 2.08–34.53, p = 0.001) or who reported being employed in the last 12 months (adjOR 2.15, 95%CI 1.31–3.53, p = 0.002) were more likely to not attend the hubs. ABYM who had a friend with a PPC were more likely to attend the hubs (adjOR 0.18 95%CI 0.09–0.35, p<0.001). Most cases reported having their last HIV test at the local government health facility (58%) while most controls reported HIV-testing at a Yathu Yathu hub (82%). Among the controls, 84% (134/160) rated the hub experience as excellent. Among cases, 65% (104/161) stated they didn’t visit the hubs “due to employment”. Conclusions Despite Yathu Yathu services being community-based and more accessible compared to health facilities, we found age, education and employment were associated with not attending hubs. Strategies are needed to reach employed young men who may not have access to SRH/HIV services during conventional working hours and to better utilise peer networks to increase service use.

Background The growing population of adolescents and young people (AYP) aged 15 to 24 in sub-Saharan Africa face a high burden of HIV in many settings. Unintended pregnancies among adolescent girls in the region remain high. Nonetheless, the sexual and reproductive health (SRH) service needs of AYP have remained underserved. We conducted a cluster-randomised trial (CRT) to estimate the impact of community-based, peer-led SRH service provision on knowledge of HIV status and other SRH outcomes, including met need for contraceptives. Methods and findings Yathu Yathu was a cluster-randomised trial (CRT) conducted from 2019 to 2021 in 2 urban communities in Lusaka, Zambia. The communities were divided into 20 zones (approximately 2,350 AYP/zone) that were randomly allocated to the Yathu Yathu intervention or control arm. In each intervention zone, a community-based hub, staffed by peer support workers, was established to provide SRH services. In 2019, a census was conducted in all zones; all consenting AYP aged 15 to 24 were given a Yathu Yathu card, which allowed them to accrue points for accessing SRH services at the hub and health facility (intervention arm) or the health facility only (control arm). Points could be exchanged for rewards, thus acting as an incentive to use SRH services in both arms. We conducted a cross-sectional survey in 2021 to estimate the impact of Yathu Yathu on the primary outcome: knowledge of HIV status (self-reporting living with HIV or HIV testing in the last 12 months) and secondary outcomes, including use of pre-exposure prophylaxis (PrEP) in the last 12 months, current use of antiretroviral therapy (ART), and met need for contraceptive services. The sampling was stratified on sex and age group, and we analysed data at cluster-level using a two-stage process recommended for CRTs with <15 clusters/arm. A total of 1,989 AYP consented to participate in the survey (50% male); consent was similar across arms (63% consent/arm). Across zones, knowledge of HIV status ranged from 63.6% to 81.2% in intervention zones and 35.4% to 63.0% in control zones. Adjusting for age, sex, and community, knowledge of HIV status was higher in the intervention arm compared to control (73.3% versus 48.4%, respectively, adjusted prevalence ratio (PR) 1.53 95% CI 1.36, 1.72; p < 0.001). By age and sex, results were similar. There was no evidence for impact on any secondary outcomes, including current use of ART and met need for contraceptives. There were no adverse events reported in either arm. A key limitation of our trial is that approximately 35% of the AYP randomly selected for participation in the endline survey could not be reached. Conclusions Delivering community-based, peer-led SRH services increased knowledge of HIV status among AYP, both males and females, compared with the control arm. Scaling up the highly effective Yathu Yathu strategy has the potential to make a substantial contribution to increasing access to HIV prevention and care services for young people. However, additional implementation research is needed to understand how to improve uptake of broader SRH services, beyond uptake of HIV testing. Trial registration ISRCTN75609016, clinicaltrials.gov number NCT04060420

Background Globally, millions of adolescent girls and young women (AGYW) who menstruate have limited access to appropriate and comfortable products to manage their menstruation. Yathu Yathu was a cluster randomised trial (CRT) that estimated the impact of community-based, peer-led sexual and reproductive health (SRH) services on knowledge of HIV status among adolescents and young people aged 15–24 (AYP). Among the services offered through Yathu Yathu were free disposable pads and menstrual cups. This study aimed to investigate whether the availability of free menstrual products through Yathu Yathu increased AGYW’s use of an appropriate menstrual product at their last menstruation and explored the characteristics of AGYW who accessed menstrual products through Yathu Yathu. Methods Yathu Yathu was conducted between 2019 and 2021 in 20 zones across two urban communities of Lusaka, Zambia. Zones were randomly allocated to the intervention or standard-of-care arm. In intervention zones, a community-based hub, staffed by peers, was established to provide SRH services. In 2019, a census was conducted in all zones; all consenting AYP aged 15–24 were given a Yathu Yathu Prevention Points Card, which allowed AYP to accrue points for accessing services at the hub and health facility (intervention arm), or the health facility only (control arm). Points could be exchanged for rewards, thus acting as an incentive in both arms. We conducted a cross-sectional survey in 2021 to estimate the impact of Yathu Yathu on the primary outcome (knowledge of HIV status) and secondary outcomes. Sampling was stratified by sex and age group; we analysed data from AGYW only to estimate the impact of Yathu Yathu on use of an appropriate menstrual product (disposable or reusable pad, cup, tampon) at last menstruation. We analysed data at zone-level using a two-stage process recommended for CRTs with < 15 clusters/arm. Results Among 985 AGYW participating in the survey who had experienced menarche, the most commonly used products were disposable pads (88.8%; n = 875/985). At their last menstruation, 93.3% (n = 459/492) of AGYW in the intervention arm used an appropriate menstrual product compared to 85.7% (n = 420/490) in the control arm (adjPR = 1.09 95%CI 1.02, 1.17; p = 0.02). There was no evidence for interaction by age (p = 0.20), but use of appropriate products was higher among adolescents in the intervention arm relative to control (95.5% vs 84.5%, adjPR = 1.14 95%CI 1.04, 1.25; p = 0.006) with no evidence for a difference among young women (91.1% vs 87.0%, adjPR = 1.06 95%CI 0.96, 1.16, p = 0.22). Conclusions Delivering community-based peer-led SRH services increased the use of appropriate menstrual products among adolescent girls aged 15–19 at the start of the Yathu Yathu study. With less economic independence, the free provision of appropriate menstrual products is critical for adolescent girls to access materials that allow them to effectively manage their menstruation.

IntroductionBroad Brush Surveys (BBS) are a rapid, qualitative assessment approach using four meta-indicators -physical features, social organization, social networks and community narratives - to gauge how local context interfaces with service/intervention options, implementation and uptake.MethodsIn 2021, responding to rapid urbanization and the accompanying need for water and sanitation services, BBS was innovatively applied by social scientists and engineers to assess water and sanitation infrastructure, both formal and informal, in two African cities - Lusaka and Cape Town. In four urban communities, identified with local stakeholders, BBS data collection included: four mapping group discussions with local stakeholders (participants = 24); eight transect walks/drives; 60 structured observations of water and sanitation options, transport depots, health facilities, weekends, nights, rainy days; seven mixed gender focus group discussions (FGDs) with older and young residents (participants = 86); 21 key-informant interviews (KII, participants = 21).ResultsFindings were rapidly summarized into community profiles, including narrative reports, maps and posters, and first discussed with community stakeholders, then at national/provincial levels. The meta-indicator framework and set sequence of qualitative activities allowed the detail on water and sanitation to gradually emerge. For example, the mapping discussion identified water sources considered a risk for waterborne infections, further observed in the transect walks and then structured observations, which compared their relative condition and social interactions and what local residents narrated about them. FGDs and KIIs elaborated on the control of these sources, with nuanced detail, including hidden sources and the use of different water sources for different activities also emerging.DiscussionWe demonstrated that despite some limitations, BBS provided useful insight to systems and social processes surrounding formal and informal water and sanitation infrastructure in and across designated urban areas. Furthermore, BBS had the potential to galvanize local action to improve infrastructure, and illuminated the value of informal options in service delivery.

Background Access to affordable and effective menstrual hygiene products (MHP) is critical to the menstrual health of adolescent girls and young women (AGYW). In this mixed-methods analysis, we use data from a programme delivering comprehensive sexual and reproductive health (SRH) services to describe access to MHP and how COVID-19-related closures affected access to MHP; we use qualitative data to understand AGYW’s experience accessing products during the study. Methods Between September 2019-January 2021, we used data routinely collected from ten Yathu Yathu hubs offering community-based, peer-led SRH services to adolescents and young people aged 15–24. Hubs offered free MHP (primarily disposable pads) as a service. To incentivise service access, a “loyalty” card system was embedded within Yathu Yathu, allowing individuals to gain points for services accessed and redeem rewards using these points. Branded pads, tampons and reusable pads were among available rewards. We describe access to service pads and to reward MHP, and use logistic regression to investigate factors associated with accessing pads and reward products before (Sept 2019-March 2020) and after (July 2020-Jan 2021) COVID-19-related closures. Focus group discussions explored accessibility of offering MHP through hubs. Results Between September 2019-January 2021, 6374 AGYW made 34,116 hub visits to access an SRH service and/or redeem a reward. At 30% of these visits, AGYW accessed any MHP. Before COVID19-closures, an average of 17% of monthly visits were for freely-available disposable pads compared to 34% after hubs reopened ( p < 0.001). Results were similar for reward visits. Overall, 63% of 6374 AGYW collected pads as a service at least once. Prior to COVID19-closures, AGYW aged 18–24 were more likely to access service pads than adolescents (15–17-years). After reopening, access was lower among older AGYW. Prior to hub closures, uptake of reward MHP was higher among AGYW with some secondary education but not after reopening. Discussions revealed that, for adolescents aged 15–19, COVID-19-related hub closures required reverting to using ineffective materials to manage menstruation. Conclusion Availability of MHP through Yathu Yathu provided a large number of AGYW with access to these products. Hubs seemed particularly important for adolescent girls. Community-based, peer-led hubs should be considered as spaces to provide AGYW access to affordable and effective MHP.

Introduction The HPTN 071 (PopART) trial demonstrated that universal HIV testing-and-treatment reduced community-level HIV incidence. Door-to-door delivery of HIV testing services (HTS) was one of the main components of the intervention. From an early stage, men were less likely to know their HIV status than women, primarily because they were not home during service delivery. To reach more men, different strategies were implemented during the trial. We present the relative contribution of these strategies to coverage of HTS and the impact of community hubs implemented after completion of the trial among men. Methods Between 2013 and 2017, three intervention rounds (IRs) of door-to-door HTS delivery were conducted in eight PopART communities in Zambia. Additional strategies implemented in parallel, included: community-wide "Man-up" campaigns (IR1), smaller HTS campaigns at work/social places (IR2) and revisits to households with the option of HIV self-testing (HIVST) (IR3). In 2018, community "hubs" offering HTS were implemented for 7 months in all eight communities. Population enumeration data for each round of HTS provided the denominator, allowing for calculation of the proportion of men tested as a result of each strategy during different time periods. Results By the end of the three IRs, 65-75% of men were reached with HTS, primarily through door-to-door service delivery. In IR1 and IR2, "Man-up" and work/social place campaigns accounted for similar to 1 percentage point each and in IR3, revisits with the option of self-testing for similar to 15 percentage points of this total coverage per IR. The yield of newly diagnosed HIV-positive men ranged from 2.2% for HIVST revisits to 9.9% in work/social places. At community hubs, the majority of visitors accepting services were men (62.8%). In total, we estimated that similar to 36% (2.2% tested HIV positive) of men resident but not found at their household during IR3 of PopART accessed HTS provided at the hubs after trial completion. Conclusions Achieving high coverage of HTS among men requires universal, home-based service delivery combined with an option of HIVST and delivery of HTS through community-based hubs. When men are reached, they are willing to test for HIV. Reaching men thus requires implementers to adapt their HTS delivery strategies to meet men's needs. Clinical Trial Number NCT01900977

Across Sub-Saharan Africa, adolescents and young people (AYP) aged 15-24 have limited access to sexual and reproductive health (SRH) services, including HIV testing services (HTS). In response, the Yathu Yathu study was implemented in two high-density communities in Lusaka, Zambia. Yathu Yathu provides comprehensive, community-based, peer-led SRH services, including differentiated HTS (finger-prick and HIV self-testing) and comprehensive sexuality education (CSE). We describe adaptations to the Yathu Yathu intervention in response to the COVID-19 epidemic, and implications on uptake of HTS among AYP. Yathu Yathu provides SRH services through community-based peer-led spaces. AYP in study communities were offered prevention points cards (PPC), which incentivizes and tracks service use. Social media (WhatsApp©/Facebook©) is used to engage and inform AYP about SRH. Due to COVID-19, hubs closed from April-June 2020. We describe adaptations in response to COVID-19 and, using routinely collected PPC data, describe uptake of HTS before (September 2019-March 2020) and after (July-December 2020) adaptations in response to COVID-19. We describe reach of the Yathu Yathu Facebook page and use qualitative data to describe AYP experiences of SRH service access. During hub closures, CSE was delivered via video on social media, resulting in an increase in Facebook page followers from 539(April) to 891(June). WhatsApp groups evolved as a platform to deliver CSE and COVID-19 information, with higher participation among young people aged 20-24. Key service delivery adaptations included: reducing the number of participants in hubs, mandatory handwashing before entry, use of personal protective equipment by staff and provision of facemasks to AYP. HTS were provided as normal. Adaptations led to fewer AYP attending hubs. Uptake of HTS among AYP visiting hubs for the first time after COVID-19-related closures was higher (73.2%) compared to uptake before adaptations (65.9%; adjOR=1.24 95%CI 0.99, 1.56, p=0.06). Despite disappointments with some aspects of service delivery, AYP expressed happiness that hubs had reopened. Social media can be a useful additional platform to reach AYP with HIV prevention information during COVID-19. With proper infection control in place, HTS can safely be provided to, accessed and accepted by AYP in community-based settings during COVID-19. National Clinical Trials NCT04060420,19th August 2019. Current Controlled Trials ISRCTN75609016 , 14th September 2021, retrospectively registered.

Adolescents and young people aged 15-24 are underserved by available HIV-testing services (HTS). Delivering HTS through community-based, peer-led, hubs may prove acceptable and accessible to adolescents and young people, thus increasing HIV-testing coverage. We used data from the pilot phase of a cluster-randomised trial of community-based sexual and reproductive health services for adolescents and young people in Lusaka, Zambia, between September 2019 and January 2020, to explore factors associated with uptake of HTS through community-based hubs. 5,757 adolescents and young people attended the hubs (63% female), among whom 75% tested for HIV (76% of females, 75% of males). Community-based hubs provided HTS to 80% of adolescents and young people with no history of HIV-testing. Among females, uptake of HTS was lower among married/cohabiting females; among males, uptake was lower among unmarried males and among individuals at risk of hazardous alcohol use. The high number of adolescents and young people accessing hubs for HIV testing suggests they are acceptable. Enhanced targeting of HTS to groups who may not perceive their HIV risk needs to be implemented.

BACKGROUND:In a cluster-randomised trial (CRT) of combination HIV prevention (HPTN 071 (PopART)) in 12 Zambian communities and nine South African communities, carried out from 2012 to 2018, the intervention arm A that offered HIV treatment irrespective of CD4 count did not have a significant impact on population level HIV incidence. Intervention arm B, where HIV incidence was reduced by 30%, followed national guidelines that mid trial (2016) changed from starting HIV treatment according to a CD4 threshold of 500 to universal treatment. Using social science data on the 21 communities, we consider how place (community context) might have influenced the primary outcome result. METHODS:A social science component documented longitudinally the context of trial communities. Data were collected through rapid qualitative assessment, interviews, group discussions and observations. There were a total of 1547 participants and 1127 observations. Using these data, literature and a series of qualitative analysis steps, we identified key community characteristics of relevance to HIV and triangulated these with HIV community level incidence. RESULTS:Two interdependent social factors were relevant to communities' capability to manage HIV: stability/instability and responsiveness/resistance. Key components of stability were social cohesion; limited social change; a vibrant local economy; better health, education and recreational services; strong institutional presence; established middle-class residents; predictable mobility; and less poverty and crime. Key components of responsiveness were community leadership being open to change, stronger history of HIV initiatives, willingness to take up HIV services, less HIV-related stigma and a supported and enterprising youth population. There was a clear pattern of social factors across arms. Intervention arm A communities were notably more resistant and unstable. Intervention arm B communities were overall more responsive and stable. CONCLUSIONS:In the specific case of the dissonant primary outcome results from the HPTN 071 (PopART) trial, the chance allocation of less stable, less responsive communities to arm A compared to arm B may explain some of the apparently smaller impact of the intervention in arm A. Stability and responsiveness appear to be two key social factors that may be relevant to secular trends in HIV incidence. We advocate for a systematic approach, using these factors as a framework, to community context in CRTs and monitoring HIV prevention efforts. TRIAL REGISTRATION:ClinicalTrials.gov NCT01900977 . Registered on July 17, 2013.

Abstract Background Meeting the sexual and reproductive health (SRH) needs of adolescents and young people (AYP) requires their meaningful engagement in intervention design. We describe an iterative process of engaging AYP to finalise the design of a community-based, peer-led and incentivised SRH intervention for AYP aged 15–24 in Lusaka and the lessons learnt. Methods Between November 2018 and March 2019, 18 focus group discussions, eight in-depth interviews and six observations were conducted to assess AYP’s knowledge of HIV/SRH services, factors influencing AYP’s sexual behaviour and elicit views on core elements of a proposed intervention, including: community-based spaces (hubs) for service delivery, type of service providers and incentivising service use through prevention points cards (PPC; “loyalty” cards to gain points for accessing services and redeem these for rewards). A total of 230 AYP (15 participated twice in different research activities) and 21 adults (only participated in the community mapping discussions) participated in the research. Participants were purposively selected based on age, sex, where they lived and their roles in the study communities. Data were analysed thematically. Results Alcohol and drug abuse, peer pressure, poverty, unemployment and limited recreation facilities influenced AYP’s sexual behaviours. Adolescent boys and young men lacked knowledge of contraceptive services and all AYP of pre and post exposure prophylaxis for HIV prevention. AYP stated a preference for accessing services at “hubs” located in the community rather than the health facility. AYP considered the age, sex and training of the providers when choosing whom they were comfortable accessing services from. PPCs were acceptable among AYP despite the loyalty card concept being new to them. AYP suggested financial and school support, electronic devices, clothing and food supplies as rewards. Conclusions Engaging AYP in the design of an SRH intervention was feasible, informative and considered responsive to their needs. Although AYP’s suggestions were diverse, the iterative process of AYP engagement facilitated the design of an intervention that is informed by AYP and implementable. Trial registration This formative study informed the design of this trial: ClinicalTrials.gov, NCT04060420. Registered 19 August, 2019.

BACKGROUND:In sub-Saharan Africa, the growing population of adolescents and young people aged 15 to 24 face a high burden of HIV, and other preventable and treatable sexually transmitted infections. Despite this burden, adolescents and young people are the population least served by available sexual and reproductive (SRH) services. This trial aims to evaluate the impact of community-based peer-led SRH services, combined with a novel incentivised "loyalty card" system, on knowledge of HIV status and coverage of SRH services.METHODS:A cluster-randomised trial (CRT) with embedded process and economic evaluation.DISCUSSION:With little available evidence of the impact of community-based, peer-led services on coverage of SRH services, our study will provide evidence critical to expanding our knowledge of how to reach adolescents and young people. The "loyalty card" system is also a novel approach to providing SRH services. The delivery of community-based services supported by incentives in the form of loyalty cards is innovative, and may prove a simple strategy to improve access to SRH services. Adolescents and young people remain underserved by available SRH services; there remains a critical need to identify ways to provide adolescents and young people with access to SRH services. Rigorous evidence of whether this innovative strategy, with strong links to the local health facility, increases coverage of critical SRH services would add to the evidence-base of how to reach adolescents and young people.